
- Vol 39, Issue 11
“I’m Homeless and I Have PTSD”
Working with homeless patients can be exceedingly rewarding.
TALES FROM THE CLINIC
In this installment of Tales From the Clinic: The Art of Psychiatry, we examine the case of posttraumatic stress disorder (PTSD) in the setting of homelessness and
Case Study
“Ms Harris” is a middle-aged woman with a history of PTSD and
Ms Harris was raped by an uncle at age 12 and advised by her mother to keep the incident a secret. After the rape, she started struggling with academic performance and she stopped attending school at age 16. She married at age 19 and quickly had 2 children. Her husband was physically and emotionally abusive in their marriage. She started drinking alcohol to cope with the abuse. She divorced her husband after 20 years of marriage when her youngest child turned 18. She received a small financial settlement after the divorce but had exhausted her savings after 3 years. She was unable to sustain employment because of her
Ms Harris is seen by a psychiatrist after completing the first 30 days of her sobriety. She is visibly anxious with significant psychomotor agitation. She reports difficulty with sleep initiation as well as
Psychological Considerations
Distrust of others is a well-known symptom of
During Ms Harris’ initial visit, she is reminded that her participation in the appointment is voluntary and confidential. Prior to giving a trauma history, she is advised that while she may be asked about broad categories of abuse, she can decline to answer any questions that make her uncomfortable and request that no trauma history be obtained at the initial visit. She is invited to provide any details that she does feel comfortable discussing, but is reassured that she will not be asked to divulge any painful details of her past. Ms Harris discusses that she had been sexually abused as a child and physically abused as an adult, but declines to provide further details during the first few visits.
Substance Use
During the initial interview, Ms Harris has some ambivalence about her alcohol use. While she understands that her use had escalated to an unhealthy level, she also reports that it was her primary means of coping with her
Ms Harris is not alone in her difficulties with alcohol use. Some studies show the prevalence of alcohol dependence in homeless patients to be upward of 55%, and similar rates of drug dependency.3 In emergency departments, rates of substance use were significantly higher, sometimes doubled, in homeless patients compared with those who did not report homelessness.4 While there are many hypotheses surrounding these findings, one cannot ignore the influence of trauma.
Pharmacologic Considerations
Ms Harris is initially started on sertraline for PTSD. Given her distrust of others and perceived failure of another selective serotonin reuptake inhibitor, considerable time is spent in psychoeducation surrounding the role and effects of medications in her treatment plan. She is also started on naltrexone for alcohol use disorder. Trazodone is used for sleep initiation difficulties.
In subsequent visits, the patient reveals that she is having nightmares surrounding the physical abuse by her ex-husband. She reports that the dream frequency has not changed with the initiation of her other medications. Doxazosin is added. Although more research is needed in patients with comorbid
Other treatment options aimed at addressing her anxiety, such as hydroxyzine and gabapentin, are discussed but declined by the patient because of a fear of daytime sedation. Topiramate is also discussed, as it has shown promise in patients with cooccurring PTSD and alcohol use disorder, although additional studies are needed.7 Ultimately, this medication is also omitted from the treatment plan because of the potential for cognitive deficits, which could impair her ability to participate fully in her substance use treatment program.
Progress
The shelter helps Ms Harris remain adherent with her medications with frequent reminders and scheduled medication times. She participates in cognitive behavioral therapy (CBT)-based substance use treatment classes as well as group and individual therapy. She engages in prolonged exposure for her traumas. Over many weeks, Ms Harris begins to trust her psychiatrist and engage in more peer support activities. Her emotional and physical reactivity improve. With the help of the shelter’s case manager, Ms Harris is able to obtain work in the retail industry. As graduation approaches, she becomes more anxious. Her psychiatrist initiates a CBT-based model aimed at addressing her cognitive distortions surrounding her ability to be successful outside a structured setting. Ms Harris graduates from the substance treatment program and moves into an apartment.
She is followed closely by her psychiatrist after graduation. Immediately following her transition out of the shelter, the patient reports a recurrence of anxiety and sleep disturbance. In addition, she reports a relapse after being offered alcohol by a well-meaning neighbor. While initially struggling with significant shame and guilt, the patient is able to abstain from further use. Trazodone is transiently increased, and Ms Harris continues to address her anxiety in therapy with positive effect.
After many months, Ms Harris becomes romantically involved with a neighbor at her apartment complex. She reports an improvement in her anxiety and continued sobriety in the weeks following the start of their relationship. She is lost to follow-up.
Setbacks
Ms Harris returns to the clinic after 1 year. She reports that her boyfriend did not support her use of psychiatric medications and advised her to stop them. He soon became increasingly emotionally abusive and the patient relapsed on alcohol. Two weeks ago, he sexually assaulted her after she declined to have intercourse. She has not told anyone about the assault but ended the relationship. She reports feeling fearful because the man still lives in her apartment complex.
Her psychiatrist provides emotional support while encouraging the patient to report the assault to the police and consider seeking a restraining order in accordance with state law. She is also encouraged to obtain urgent gynecologic care and is given information about a local family violence shelter. While the patient declines to report the incident to the police or seek resources from the family violence shelter, she agrees to seek gynecologic care. The patient restarts her medications and is able to taper off alcohol as an outpatient.
Concluding Thoughts
Working with homeless patients can be exceedingly rewarding. Patients such as Ms Harris can and do improve at a remarkable rate with the appropriate support and treatment. However, there are also challenges facing psychiatrists who work with homeless patients (
Dr Williams is assistant professor at the Meninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She specializes in homeless populations with cooccurring psychiatric illnesses and serves as the departmental lead medical students elective officer and associate clerkship director.
References
1. Hepp J, Schmitz SE, Urbild J, et al.
2. Trauma-Informed Care in Behavioral Health Services.
3. Fazel S, Khosla V, Doll H, Geddes J.
4. Doran KM, Rahai N, McCormack RP, et al.
5. Pietrzak RH, Goldstein RB, Southwick SM, Grant BF.
6. Back SE, Flanagan JC, Jones JL, et al.
7. Flanagan JC, Korte KJ, Killeen TK, Back SE.
8. Waegemakers Schiff J, Lane AM.
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